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投稿时间：2024-02-20 网络发布日期：2024-12-21
投稿时间：2024-02-20 网络发布日期：2024-12-21
中文摘要: 目的 评价依据肺静态顺应性（Cstat）为导向设定最佳呼气末正压（PEEP）对胸外科手术患者肺功能的影响。 方法 选取临沂市人民医院2022年9月至2023年5月择期行胸腔镜下肺叶切除术的患者60例，随机分为试验组和对照组，每组30例。试验组单肺通气后先行肺复张，然后依据Cstat为导向，采用PEEP递减法寻找最佳PEEP，对照组单肺通气后PEEP设为5 cmH2O。记录4个时间点：麻醉诱导插管后（T1）、单肺通气开始即刻(T2)和PEEP设定后30 min（T3）、PEEP设定后60 min(T4)，记录各组各时间点的血流动力学指标 [心率（HR）、平均动脉压（MAP）]以及呼吸力学指标 [气道平台压（Pplat）、Cstat、驱动压（DP）]，并于上述时间点抽取患者的动脉血和混合静脉血行血气分析，检测动脉血氧分压（PaO2）并计算氧合指数（OI）、肺内分流率(QS/QT)、死腔分数(VD/VT),分别于单肺通气开始时和结束后抽取动脉血检测炎症因子 [白细胞介素-6（IL-6）、肿瘤坏死因子（TNF-ɑ） ]水平。结果 试验组Cstat达到最大时，PEEP值为（7.67±0.80）cmH2O。两组患者由双肺通气转为单肺通气后，氧合指数下降，QS/QT增加，Cstat降低。单肺通气期间，相比于对照组，试验组在T3、T4时间点上的Cstat更高（P＜0.05＝，DP更低(P＜0.01＝，OI更高（P＜0.05)，QS/QT更低（P＜0.05＝。试验组在单肺通气结束后IL-6水平明显低于对照组（P＜0.05)。结论 胸外科手术单肺通气期间患者的氧合指数下降、肺内分流增加，肺顺应性降低；相比于固定PEEP(5 cmH2O),依据Cstat设定的个体化PEEP值可显著减少肺内分流，改善术中氧合，降低DP，增加肺顺应性，抑制炎症反应。
Abstract:Objective To evaluate the effect of setting the optimal positive end-expiratory pressure (PEEP) based on static compliance (Cstat) on pulmonary function in patients undergoing thoracic surgery. Methods Sixty patients scheduled for elective video-assisted thoracoscopic lobectomy at Linyi People’s Hospital from September 2022 to May 2023 were randomly divided into an experimental group and a control group, with 30 cases in each group. In the experimental group, after one-lung ventilation, lung recruitment was first performed, followed by finding the optimal PEEP using a decremental PEEP trial guided by Cstat. PEEP was set at 5 cmH2O after one-lung ventilation in the control group. Hemodynamic parameters [heart rate (HR), mean arterial pressure (MAP)], and respiratory mechanics parameters [airway plateau pressure (Pplat), Cstat, driving pressure (DP)] were recorded at four time points: after induction of anesthesia and intubation (T1), immediately after the start of one-lung ventilation (T2), and 30 min (T3) and 60 min (T4) after PEEP setting. Arterial and mixed venous blood gas analyses were performed at these time points to measure pressure of arterial oxygen (PaO2) and calculate the oxygenation index (OI), intrapulmonary shunt fraction (QS/QT), and dead space fraction (VD/VT). Inflammatory cytokines [interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-ɑ)] levels were also measured in arterial blood samples taken at the beginning and end of one-lung ventilation. Results When the Cstat of the experimental group reached its maximum, the PEEP value was (7.67±0.80) cmH2O. After transitioning from two-lung to one-lung ventilation, both groups experienced a decrease in OI, an increase in QS/QT, and reduced Cstat. During one-lung ventilation, compared to the control group, the experimental group had higher Cstat (P＜0.05), lower DP (P＜0.01), higher OI (P＜0.05), and lower QS/QT (P＜0.05) at T3 and T4. The experimental group also had significantly lower IL-6 levels than the control group after one-lung ventilation ended (P＜0.05). Conclusion During one-lung ventilation in thoracic surgery, patients experience a decrease in OI, an increase in QS/QT, and reduced lung compliance; compared to a fixed PEEP (5 cmH2O), individualized PEEP values set based on Cstat can significantly reduce intrapulmonary shunt, improve intraoperative oxygenation, decrease DP, increase lung compliance, and suppress inflammatory responses.
keywords: One-lung ventilation Positive end-expiratory pressure Static compliance Intrapulmonary shunt Lung protective ventilation strategies
文章编号： 中图分类号：R614 文献标志码：A
基金项目:徐州医科大学附属医院科技发展基金面上项目（XYFM202221）
附件
| 作者 | 单位 |
| 李梦婷 | 1. 山东第二医科大学麻醉学院，山东 潍坊 261053；2. 徐州医科大学附属临沂市人民医院麻醉科，山东 临沂 276000 |
| 卢静 | 2. 徐州医科大学附属临沂市人民医院麻醉科，山东 临沂 276000 |
引用文本：
李梦婷,卢静.个体化呼气末正压对胸外科手术患者肺功能的影响[J].中国临床研究,2024,37(12):1875-1880.
李梦婷,卢静.个体化呼气末正压对胸外科手术患者肺功能的影响[J].中国临床研究,2024,37(12):1875-1880.